Highmark Medicare Services

12102, 12202, 12302

MAC Part A & B

A47798

Article

No

Chiropractic Services

A47798

Maryland, District of Columbia, DELAWARE

07/11/2008

N/A

N/A

Coding Guidelines
The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits. This policy does not take precedence over CCI edits. Please refer to CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.

When billing for Chiropractic services:

• Report the initial treatment phase.
• Report the date of X-ray if an X-ray is used to demonstrate subluxation. The X-ray film must be available for review upon request.
• A physical examination may be used to document subluxation if an X-ray is not used.  Report all that apply by using the letters P, A, R and/or T as follows:

  (P)	Pain/tenderness evaluated in terms of location, quality, and intensity;
  (A)	Asymmetry/misalignment identified on a sectional or segmental level;
  (R)	Range of motion abnormality (changes in active, passive, and accessory joint movements resulting in an increase or a decrease of sectional or segmental mobility); and
  (T)	Tissue, tone changes in the characteristics of contiguous, or associated soft tissues, including skin, fascia, muscle, and ligament.

• Report the level of subluxation using the appropriate ICD-9-CM code.
• In addition to reporting the ICD-9-CM code for the level of subluxation, report any other pertinent ICD-9-CM codes.
• As per the definitions supplied in LCD L27480, all treatments must be categorized as either acute subluxation, chronic subluxation or maintenance therapy. An exacerbation of a previous injury should be categorized into either "acute" or "chronic" (e.g., an identifiable re-injury would fall under acute).

The following modifiers should be reported with procedure code 98940, 98941, or 98942 as is appropriate to each patient's situation:

For Medicare purposes, the AT modifier shall now be used only when chiropractors bill for active/corrective treatment.

Reasons for Denial
Excluded from Medicare coverage is any service other than manual manipulation for the treatment of subluxation of the spine. The chiropractor is not required to bill excluded services.  However, if the beneficiary requests Medicare be billed, the provider must bill services to Medicare in order to obtain a denial for secondary insurance purposes. The following are examples (not an all-inclusive list) of services excluded from Medicare coverage when performed by a chiropractor; the beneficiary is responsible for payment.

• Laboratory tests
• X-rays
• Office visits (history and physicals)
• Physiotherapy
• Traction
• Supplies
• Injections
• Drugs
• EKGs or any diagnostic study
• Acupuncture
• Orthopedic devices
• Nutritional supplements/counseling
• Any service ordered by the chiropractor

In addition, services will be denied, prospectively as well as retrospectively, when:

• the contractor determines that the service is not medically reasonable and necessary; and/or
• the guidelines of LCD L27480 are not followed; and/or
• the medical record does not verify that the service described by the HCPCS code was provided; and/or
• there exists one of the absolute contraindications; and/or
• the mechanical or electric equipment, that is used for manipulation does not meet the definition of "manual device" as specified in the "Description" section of LCD L27480; and/or
• an X-ray or physical exam does not support one of the primary diagnoses listed in the "ICD-9 Codes That Support Medical Necessity" section of LCD L27480; and/or
• the service was performed as maintenance therapy; and/or
• the documentation, in the medical record is lacking the information required under the "Documentation Requirements" section of LCD 27480.

Chiropractic Services

The diagnosis code reported must be representative of the patient's condition.

LCD L27480 is not intended to be interpreted as reflecting chiropractic scope of practice, but rather reflecting chiropractic coverage under the Medicare program.

A47798